This document was prepared for Arlington County by Titan Systems Corporation. It was accomplished through a grant from, and the support of, the Department of Justice, Office of Justice Programs, Office for Domestic Preparedness, under Contract Number GS10F0084K, Order Number 2001F_341.
TABLE OF CONTENTS
Introduction
Annex A – Fire Department Operations
Section 1: Initial Response...... A-4 Section 2: Command, Coordination, and the Incident Command System...... A-20 Section 3: Communications...... A-34 Section 4: Recall and Staffing...... A-39 Section 5: Mutual-Aid and Outside Support ...... A-44 Section 6: Logistics ...... A-53 Section 7: Site Safety, Security, and Personnel Accountability ...... A-65 Section 8: Planning, Training, and Preparedness...... A-73
Annex B – Hospitals and Clinics
Section 1: Initial Response...... B-2 Section 2: Communications...... B-7 Section 3: Disaster Operations ...... B-9 Section 4: Patient Care...... B-12 Section 5: Planning, Training, and Preparedness...... B-17
Annex C – Law Enforcement
Part I. Arlington County Law Enforcement Section 1: Initial Response...... C-6 Section 2: Command, Communications, and the Incident Command System ...... C-13 Section 3: Operations...... C-20 Part II. Defense Protective Service Section 1: Initial Response...... C-31 Section 2: Command, Communications, and the Incident Command System ...... C-35 Section 3: Operations...... C-38 Part III. Federal Bureau of Investigation Section 1: Initial Response...... C-45 Section 2: Command, Communications, and the Incident Command System ...... C-49 Section 3: Operations...... C-54
Annex D – Emergency Management and the Emergency Operations Center
Appendices
1 – 24-Hour Timeline 2 – Acronym List 3 – Data Reference Directory 4 – Pentagon Penetration Damage Diagrams
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LIST OF FIGURES
Figure 1. Arlington County Government, Public Safety, and Medical Facilities ...... 5 Figure 2. Pentagon Ingress and Egress and Completed Wedge One ...... 8
Figure A-1. ACFD Organization ...... A-1 Figure A-2. Arlington County Fire Stations ...... A-2 Figure A-3. Initial Triage and Treatment Sites...... A-12 Figure A-4. EMS Branch Structure...... A-14 Figure A-5. Post-Evacuation Triage and Treatment Sites...... A-15 Figure A-6. Initial Incident Command Structure ...... A-23 Figure A-7. Final Triage, Treatment, and Rehabilitation Locations...... A-27 Figure A-8. ECC Floor Plan ...... A-34 Figure A-9. Incident Response Resources Support ...... A-47 Figure A-10. Pentagon Logistics Support Area...... A-54 to A-55 Figure A-11. Outer Perimeter Security Fence ...... A-70
Figure B-1. Area Hospitals, Clinics, and Treatment Facilities...... B-2 Figure B-2. DTHC Triage and Treatment Areas ...... B-4 Figure B-3. Victim Disposition...... B-15
Figure C-1. ACPD Districts and Precincts ...... C-2 Figure C-2. ACPD ICS Organization Chart ...... C-14 Figure C-3. ACPD Posts at Entry Points to the Pentagon ...... C-20 Figure C-4. Locations of Agencies, Organizations, and Operational Sites ...... C-41 Figure C-5. Inner and Outer Perimeters ...... C-59
Figure D-1. EOC Floor Plan ...... D-3 Figure D-2. Objectives for Day 7 ...... D-8
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INTRODUCTION
Arlington County After-Action Report Introduction
ARLINGTON COUNTY AFTER-ACTION REPORT ON THE RESPONSE TO THE SEPTEMBER 11 TERRORIST ATTACK ON THE PENTAGON This After-Action Report (AAR) describes the activities of Arlington County and the supporting jurisdictions, government agencies, and other organizations in response to the September 11, 2001, terrorist attack on the Pentagon. This incident produced a unique paradigm of response considerations and requirements. It was a major fire and rescue operation within the broader context of a terrorist attack. This terrorist attack occurred in Arlington County, VA, but at a U.S. military facility under the direct control of the Secretary of Defense. The incident response engaged a large number of agencies, organizations, and individuals from all levels of government and the private sector, and it lasted for an extended period. This AAR conveys the response, rescue, and recovery activities as seen through the eyes of the response community. It is a holistic and comprehensive report, incorporating the views of persons at all levels and from all participating organizations. The information in this AAR was compiled, analyzed, and produced during a 6-month period. The AAR project team conducted 92 separate debriefing sessions and interviewed approximately 475 participants. A total of 550 survey forms were distributed to response community members in Arlington County and neighboring jurisdictions. The information collected yielded more than 2,000 data points that were subsequently integrated into nearly 800 information elements. The project team also reviewed numerous planning documents, mutual-aid agreements, journals, logbooks, and other transaction records. The extensive review of documents and materials supplemented the information received from interviews and survey forms. The information compiled for this AAR represents the views of many individuals taken at different times during the response. It produced legitimate, but often varying, perspectives. A robust three-tiered validation process was employed to ensure the information conveyed in this AAR is consistent and accurate. Tier-1 validation consisted of project team members conducting detailed technical reviews of the information collected and analyzed by other colleagues. Thus, team members had a professional colleague reviewing their material. Next, each project team member reviewed all the compiled AAR data and met to resolve conflicting information and identify anomalies. Validation interviews were then conducted with key first responders to verify preliminary findings and recommendations. Tier-2 validation engaged a group of senior response community experts in a comprehensive review, followed by debriefings and discussions between the reviewers and key project team members. Finally, senior representatives of key participating organizations reviewed and validated the Tier-3 draft report. This AAR is organized into four principal annexes and four supporting appendices. Annex A – Fire Department Operations includes all aspects of fire, rescue, and Emergency Medical Services (EMS) activities performed by Arlington County, as well as supporting jurisdictions, agencies, and organizations operating under mutual-aid or similar provisions. Annex B – Hospitals and Clinics describes the response of
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Introduction medical treatment centers throughout the Washington Metropolitan Area, including hospitals, urgent care centers, and military health clinics. Annex C – Law Enforcement presents the activities of those law enforcement agencies sharing primary jurisdictional responsibilities for this incident, the Arlington County Police Department (ACPD), the Defense Protective Service (DPS), and the Federal Bureau of Investigation (FBI), as well as many other law enforcement organizations that provided response support. Annex D – Emergency Management and the Emergency Operations Center presents the activities of the Arlington County government in support of the first responders and citizens of Arlington County. Each annex is organized somewhat differently, reflecting the nature of its content. The Introduction to each annex explains this organization. However, within the various annex parts or sections, the information is conveyed in a standard format: observations describe what transpired; findings present what was learned from the perspective of the response participants; recommendations and lessons learned describe potential improvements that were naturally derived from the findings. The remainder of this introduction sets the stage and gives the reader a context for the annexes. It describes Arlington County, VA, its form of government, and provisions for emergency management. It also describes the target of the attack, the Pentagon. Finally, it describes the events of September 11, 2001, and covers selected response efforts with a final Summary.
Arlington County, VA
Arlington County, VA, is geographically the smallest county in the United States, according to the National Association of Counties, occupying an area slightly less than 26 square miles. However, it is a bustling, compact, urban residential and business center. This was not always the case. Originally part of Fairfax County, in 1791, the Virginia General Assembly ceded the land that is now Arlington County to the Federal Government as part of the new national capital. It was returned to Virginia and designated Alexandria County in 1847. The county population in 1900 was 6,430. It became Arlington County in 1920. Today, its residential population of 190,000 grows substantially on workdays. Employees report to the many government agencies in Arlington and the private companies that support those agencies. The Pentagon alone has a workforce of more than 23,000 military and civilian personnel. Additionally, approximately 25,000 people visit Arlington’s tourist attractions each day, including Arlington National Cemetery, the Iwo Jima Memorial, and the Pentagon. Arlington County is Northern Virginia’s gateway to the Nation’s capital. Located just across the Potomac River from the District of Columbia, every highway and railway connecting Virginia and the District of Columbia runs through Arlington County. Ronald Reagan Washington National Airport is located in Arlington County. It is the 16th busiest airport in the country, with an average of 47,000 passengers daily.
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Introduction
In 1922, the Virginia Supreme Court of Appeals ruled that Arlington is a contiguous, continuous, and homogenous community and cannot be further subdivided to form a town. In 1930, Arlington became the first county in the United States to adopt the manager form of government by popular vote.
A five-member County Board sets policies and makes all legislative decisions. The members are elected at large for rotating 4-year terms. The County Board selects its chairman annually. In calendar year 2001, Mr. Jay Fisette served as Chairman. Mr. Christopher Zimmerman was Vice Chairman and succeeded Mr. Fisette on January 1, 2002. The other County Board members are Ms. Barbara Favola, Mr. Paul Ferguson, and Mr. Charles Monroe.
Arlington County Board Members Favola, Monroe, Fisette, Zimmerman, and Ferguson.
A County Manager is appointed by the County Board and serves as the chief administrative officer, exercising authority over all government functions except the public schools, which are governed by a Superintendent appointed by the School Board. More than 3,400 Arlington County employees deliver services to county residents and businesses. Citizens advisory groups including commissions, task forces, and ad-hoc committees, focus on specific needs such as the Commission on Aging and the Human Rights Commission.
Mr. Ron Carlee was appointed County Manager in April 2001. However, Mr. Carlee’s career with the Arlington County government extends more than 22 years. He previously served in the former Department of Human Services and in other county organizations. He led the county’s $20 million year 2000
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Introduction
(Y2K) effort and was thoroughly familiar with Arlington County government operations and the characteristics and needs of Arlington’s neighborhoods and citizens well before his current appointment.
In 1956, Arlington County published a Comprehensive Emergency Management Plan (CEMP) that, with several revisions, continues to serve as the framework for county emergency operations. Arlington County Code designates the County Manager as the Director of Emergency Services. The CEMP establishes an Emergency Management Team, a group of senior managers knowledgeable in field operations who serve as an advisory body to the County Manager County Manager for all aspects of preparation, disaster Ron Carlee. response, and recovery. This core group is chaired by the Assistant County Manager (Mr. John Mausert-Mooney) and includes the Police Chief (Chief Edward Flynn), Fire Chief (Chief Edward Plaugher), Director of Public Works (Mr. Sam Kem), Assistant County Manager for Public Affairs (Mr. Richard Bridges), and School Superintendent (Dr. Robert Smith). The Fire Chief is also appointed as the Arlington County Coordinator of Emergency Services. His designated Deputy Coordinator of Emergency Services, Captain Mark Penn, serves as the staff coordinator for the Emergency Management Team.
Twenty-nine percent of Arlington County’s 3,400 employees serve in its public safety organizations, the police department, the sheriff’s office, and the fire department, providing a significant level of safety and protection to its citizens.
The 10 fire stations and 10 police beats are strategically located throughout Arlington County, which is also home to important modern medical treatment facilities. (See Figure 1.)
From the moment American Airlines Flight #77 crashed into the Pentagon at 9:38 a.m. on September 11, and for the succeeding 10 days, this was a major fire and rescue incident, the responsibility of the Arlington County Fire Department (ACFD). Chief Plaugher was appointed to his position in December 1993, following 24 years with the Fairfax County Fire and Rescue Department. The ACFD force of 266 career firefighters is organized into 3 shifts with a minimum daytime staff of 67, including 15 paramedics. Last year, the ACFD responded to nearly 24,000 emergency calls.
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Figure 1. Arlington County government, public safety, and medical facilities.
When Chief Plaugher joined the ACFD more than 8 years ago, he focused on developing a more fully-integrated fire and EMS response capability. Battalion management teams were formed. An EMS captain is assigned to work with each battalion commander and with the fire/EMS officer assigned to each station. Together, they are responsible for all EMS training in the battalion. This guarantees both a better trained EMS force and the availability of two EMS captains at Fire Chief Plaugher.
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Introduction
all times. Captain Edward Blunt and Captain Alan Dorn were both on duty the morning of September 11.
Following the March 1995 sarin nerve agent attack in a Tokyo subway that killed 12 commuters and injured hundreds more, Chief Plaugher and Assistant Chief for Operations James Schwartz and Assistant Chief for Technical Support John White recognized that America’s first responders were not trained or equipped to handle such emergencies. As Chairman of the Washington Metropolitan Area Council of Governments Fire Chiefs Chemical/Biological Committee, Chief Plaugher asked that Council of Governments Chairman Jack Evans send a letter to the President of the United States. The letter described the risk of a terrorist attack and sought assistance in planning and preparing for such an event. As a result, the U.S. Public Health Service (USPHS) invited the Council of Governments to participate in a watershed project to develop the Nation’s first locally-based terrorism response team with a hazardous materials (HazMat), medical management, and mass casualty decontamination capability. Chief Plaugher and the ACFD volunteered to work with the USPHS to develop the first prototype capability. This pioneering work produced the framework for the Metropolitan Medical Response System (MMRS) now embraced by more than 100 U.S. metropolitan areas. It was the predecessor to the National Medical Response Team (NMRT), which played an important response role at the Pentagon.
The success of the ACFD response to the terrorist attack on the Pentagon did not happen by chance. The ACFD’s preparedness was the result of hard work, sound organization, extensive training, and outstanding leadership. Assistant Chief Schwartz has served in that capacity since 1997. His 18 years of experience with the ACFD and his proven leadership skills served him well when Chief Plaugher designated Chief Schwartz as the ACFD Incident Commander for the 10-day duration of the Pentagon fire and rescue operations. Assistant Chief White’s extensive experience as EMS Captain and later as EMS Battalion Chief is reflected in his ability to serve in three critical capacities during the Pentagon response. Chief Schwartz first assigned Chief White as commander of the EMS Branch. Chief White spent 10 years supervising ACFD EMS operations. Next, he was directed to establish the Incident Command System (ICS) Logistics Section with a capability of sustaining fire and rescue operations and supporting the entire response force for 10 days. Once the Logistics Section was fully operational, Chief White became the Incident Command representative at the Joint Operations Center (JOC).
Chief Edward Flynn leads the ACPD. Police Chief Flynn. Chief Flynn was appointed to his
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Introduction
current position in November 1997 after rising successively through the ranks from patrol officer to department chief while serving in communities in New Jersey and Massachusetts. Founded in 1940 with a force of 9 police officers, the ACPD now has 362 sworn officers and 85 civilian staff members. The ACPD holds the longest standing accreditation in the world from the Commission on Accreditation for Law Enforcement Agencies, Inc. (CALEA). It is responsible for all law enforcement and crime prevention services in Arlington County.
Sheriff Beth Arthur is an elected State constitutional officer. First appointed to succeed her predecessor in June 2000, Sheriff Arthur was elected to a 4-year term in November 2001. Sheriff Arthur directs a force of 270 sworn and civilian employees. The sheriff is responsible for managing the Arlington County Detention Center, courthouse security, and serving warrants. Sheriff Beth Arthur.
The Pentagon
The Pentagon is home to the Nation’s defense establishment. Located in Arlington County, VA, it has served for more than 60 years as a symbol of power in defense of freedom. Ironically, the groundbreaking ceremony for construction of the Pentagon took place on September 11, 1941, less than 3 months before the U.S. entry into World War II. Built on a site previously known as Arlington Farms, the five surrounding roadways dictated its pentagonal shape. The Pentagon’s placement was personally approved by President Franklin Roosevelt to avoid obstructing the view of the U.S. Capitol from Arlington National Cemetery. The 380,000 tons of sand dredged from the Potomac River produced the reinforced concrete used to construct the building and the 41,492 concrete piles that supported it. This innovative use of concrete saved enough steel to build an additional aircraft carrier for the War Department. Construction of the Pentagon was completed in just 16 months at a cost of $83 million.
The Pentagon is a massive structure. The building covers 29 acres of land, with a floor area of almost 7 million square feet. Almost 18 miles of corridors connect the 5 floors of office space housing some 23,000 employees. The heating and refrigeration plant alone covers a full acre and more than 100,000 miles of telephone cables run through the building. Although the network of corridors, escalators, elevators, and stairwells is designed to speed movement from place to place, to the uninitiated, maneuvering through the Pentagon can be daunting. So much so that a Web site is used to help acquaint newly assigned staff with the intricacies of Pentagon navigation.
Additionally, the Pentagon is a building in transition. An extensive renovation effort began in 1998 and will continue until 2012. Each of the five Wedges
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Introduction
comprising the facility will undergo complete modernization. On September 11, contractors were completing the final work on Wedge One, which was ready for occupancy. (See Figure 2.)
The responsibility for contingency operations at Department of Defense (DoD) facilities in the Washington Metropolitan Area, including the Pentagon, belongs to the Commanding General of the Military District of Washington (MDW), Major General James Jackson.
Figure 2. Pentagon ingress and egress and completed Wedge One.
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Introduction
September 11, 2001
On September 11, 2001, the citizens of the Washington Metropolitan Area awoke to a bright, clear morning. By 8:00 a.m., the Tuesday morning commute was well under way. At Washington Dulles International Airport, passengers were boarding American Airlines Flight #77 for the morning departure en route to Los Angeles, CA. The Boeing 757 is a large airliner with a typical transcontinental passenger capacity of 243. Its maximum takeoff weight exceeds 270,000 pounds, including 11,466 gallons of jet fuel. The cruising speed of the Boeing 757 is 475 miles per hour.
At 8:10 a.m., American Airlines Flight #77 took off from Washington Dulles International Airport carrying 58 passengers and a crew of 6. It headed west across Virginia and West Virginia, making an unscheduled left turn at the Ohio- Kentucky border. At 9:03 a.m., air traffic controllers lost contact with the airliner.
At 9:37 a.m., in Arlington County, Captain Steve McCoy and the crew of ACFD Engine 101 were en route to a training session in Crystal City, traveling north on Interstate 395. Their conversation about the World Trade Center attack earlier that morning was interrupted by the sight and sound of a commercial airliner in steep descent, banking sharply to its right before disappearing beyond the horizon. At the same time, ACPD Corporal Barry Foust and Officer Richard Cox, on patrol in south Arlington County, saw a large American Airlines aircraft in a steep dive and on a collision course with the Pentagon.
At 9:38 a.m., American Airlines Flight #77 crashed into the west side of the Pentagon, just beyond the heliport. It was traveling at a speed of about 400 miles per hour, accelerating with close to its full complement of fuel at the time of impact.
The destruction caused by the attack was immediate and catastrophic. The 270,000 pounds of metal and jet fuel hurtling into the solid mass of the Pentagon is the equivalent in weight of a diesel train locomotive, except it is traveling at more than 400 miles per hour. More than 600,000 airframe bolts and rivets and 60 miles of wire were instantly transformed into white-hot shrapnel. The resulting impact, penetration, and burning fuel had catastrophic effects to the five floors and three rings in and around Pentagon Corridors 4 and 5. (See detailed graphics in Appendix 4.)
This act of evil cost the lives of 189 persons in the Pentagon attack, 184 innocent victims, and the 5 terrorist perpetrators of the criminal attack.
Summary
The successful response to the terrorist attack on the Pentagon can be attributed to the efforts of ordinary men and women performing in extraordinary fashion. These efforts are described throughout this AAR.
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For example, fire service veterans like Chief Bob Cornwell and Captain Chuck Gibbs imparted to a new generation of firefighters air supply conservation techniques learned during the past three decades. Tactical unit commanders emphasized accountability and watched carefully over those in their charge as they searched vigilantly for surviving victims. Ms. Dodie Gill, Director of Employee Support, and her colleagues were onsite at the Pentagon within 3 hours of the attack, demonstrating that taking care to the firefighter is as important as taking care of the firefighter. Captain Lewis Cooper and Captain Mike Kilby leveraged the experience of Captain Dean Cox and his Fairfax County Fire and Rescue Department logistics team to create a superb logistics function.
With less than 24 hours on his new job as Emergency Operations Center (EOC) coordinator, Captain Penn integrated the resources of Arlington County in support of the tactical operation at the Pentagon. FBI Supervisory Special Agent (SSA) Jim Rice was undergoing chemotherapy treatments but never missed a moment of his 12-hour evidence recovery shifts. The partnership between the FBI and the ACFD was formed in advance through the initiative of Special Agent Chris Combs; it is a model that every metropolitan area should emulate. Those partnerships forged prior to the heat of battle proved invaluable. Ironically, Special Agent Combs, a former New York firefighter, lost two cousins during the response to the terrorist attacks on the World Trade Center.
An anonymous relay team of drivers transported 70 square feet of medical replacement skin, driving 23 hours nonstop from Texas to Washington Hospital Center because airplanes were grounded. Doctors Marion Jordan and James Jeng of Washington Hospital Center, working 14- to 16-hour shifts, performed 112 skin graft operations on 9 patients in 3 weeks. These and other heroes went quietly about their work with little notice.
Neighboring jurisdictions rushed to the aid of ACFD without hesitation. The first action of Alexandria’s Chief Tom Hawkins was to send a battalion chief to Chief Schwartz, the ACFD Incident Commander, to coordinate their support and deliver one simple message, “Anything you need, you’ve got.” That message characterized the attitude of Arlington’s partners during the fire and rescue operations.
One can only marvel at the combination of Chief Plaugher’s strategic vision, the tactical leadership of Chief Schwartz, the flexibility and breadth of Chief White’s capabilities, and the technical competence of the other ACFD chief officers. It is noteworthy that in one of the group debriefing sessions, with no chief officer in the room, a firefighter described, as a major positive finding, the fact that “Our chief officers were extraordinary. They were everywhere, all the time.” Given the source, this is a fitting tribute to a gallant group of leaders. Journalist Carol Hymowitz, writing about the events of September 11, observed that “These are the times that make—or break—leaders.” Leadership isn’t learned in a day; it is learned everyday. Clearly, Arlington County and particularly the ACFD were fortunate to have strong, competent leaders in place on the morning of September 11.
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Introduction
This AAR contains 235 recommendations and lessons learned, each of which must be understood within the context and setting of the Pentagon response. Some specifically apply to a particular response element or activity. Others address overarching issues that apply to Arlington County and other jurisdictions, particularly those in large metropolitan areas. They have not been weighted or prioritized. This is a task best left to those with operational responsibilities and budgetary authority.
The following examples of lessons learned are presented in two categories. The first set of examples describes areas that worked very well and contributed significantly to this successful response. They are models that other jurisdictions should emulate. The second set of examples reflects challenges that were encountered and overcome, which can now be corrected by Arlington County and avoided by others in the future. All the examples summarized here are addressed in greater detail throughout the report.
Capabilities Others Should Emulate
1. ICS and Unified Command: The primary response participants understood the ICS, implemented it effectively, and complied with its provisions. The ACFD, an experienced ICS practitioner, established its command presence literally within minutes of the attack. Other supporting jurisdictions and agencies, with few exceptions, operated seamlessly within the ICS framework. For those organizations and individuals unfamiliar with the ICS and Unified Command, particularly the military, which has its own clearly defined command and control mechanisms, the Incident Commander provided explicit information and guidance early during the response and elicited their full cooperation.
2. Mutual Aid and Outside Support: The management and integration of mutual-aid assets and the coordination and cooperation of agencies at all government echelons, volunteer organizations, and private businesses were outstanding. Public safety organizations and chief administrative officers (CAOs) of nearby jurisdictions lent their support to Arlington County. The response to the Pentagon attack revealed the total scope and magnitude of support available throughout the Washington Metropolitan Area and across the Nation.
3. Arlington County CEMP: The CEMP proved to be what its title implies. It was well thought out, properly maintained, frequently practiced, and effectively implemented. Government leaders were able to quickly marshal the substantial resources of Arlington County in support of the first responders, without interfering with tactical operations. County Board members worked with counterparts in neighboring jurisdictions and elected Federal and State officials to ensure a rapid economic recovery, and they engaged in frequent dialogue with the citizens of Arlington County.
4. Employee Assistance Program (EAP): At the time of the Pentagon attack, Arlington County already had in place an aggressive, well-established EAP offering critical incident stress management (CISM) services to public safety and other county employees. In particular, the ACFD embraced the concept and encouraged all its members to use EAP services. Thus, it is not surprising that
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Introduction
the EAP staff was well-received when they arrived at the incident site within 3 hours of the attack. During the incident response and in followup sessions weeks afterward, the EAP proved invaluable to first responders, their families, and the entire county support network. This is a valuable resource that must be incorporated in response plans.
5. Training, Exercises, and Shared Experiences: The ACFD has long recognized the possibility of a weapons of mass destruction (WMD) terrorist attack in the Washington Metropolitan Area and has pursued an aggressive preparedness program for such an event, including its pioneering work associated with the MMRS. In preparation for anticipated problems associated with the arrival of Y2K, Arlington County government thoroughly exercised the CEMP. In 1998, the FBI Washington Field Office (WFO) established a fire liaison position to work specifically with area fire departments. Washington Metropolitan Area public safety organizations routinely work together on events of national prominence and shared jurisdictional interests, such as presidential inaugural celebrations, Heads of State visits, international conferences such as the periodic International Monetary Fund (IMF) conference, and others. They also regularly participate in frequent training exercises including those hosted by the Pentagon and MDW. All this and more contributed to the successful Pentagon response.
Challenges that Must Be Met
1. Self-Dispatching: Organizations, response units, and individuals proceeding on their own initiative directly to an incident site, without the knowledge and permission of the host jurisdiction and the Incident Commander, complicate the exercise of command, increase the risks faced by bonafide responders, and exacerbate the challenge of accountability. WMD terrorist event response plans should designate preselected and well-marked staging areas. Dispatch instructions should be clear. Law enforcement agencies should be familiar with deployment plans and quickly establish incident site access controls. When identified, self-dispatched resources should be immediately released from the scene, unless incorporated into the Incident Commander’s response plan.
2. Fixed and Mobile Command and Control Facilities: Arlington County does not have a facility specifically designed and equipped to support the emergency management functions specified in the CEMP. The conference room currently used as the EOC does not have adequate space and is not configured or properly equipped for that role. The notification and recall capabilities of the Emergency Communications Center are constrained by equipment limitations and there are no protected telephone lines for outside calls when the 9-1-1 lines are saturated. The ACFD does not have a mobile command vehicle and relied on the use of vehicles belonging to other organizations and jurisdictions. The ACPD mobile command unit needs to be replaced or extensively modernized.
3. Communications: Almost all aspects of communications continue to be problematic, from initial notification to tactical operations. Cellular telephones were of little value in the first few hours and cellular priority access service (CPAS) is not provided to emergency responders. Radio channels were initially
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oversaturated and interoperability problems among jurisdictions and agencies persist. Even portable radios that are otherwise compatible were sometimes preprogrammed in a fashion that precluded interoperability. Pagers seemed to be the most reliable means of notification when available and used, but most firefighters are not issued pagers. The Arlington County EOC does not have an installed radio capacity and relied on portable radios coincidentally assigned to staff members assigned duties at the EOC.
4. Logistics: Arlington County, like most other jurisdictions, was not logistically prepared for an operation of the duration and magnitude of the Pentagon attack. The ACFD did not have an established logistics function, a centralized supply system, or experience in long-term logistics support. Stock levels of personal protective equipment (PPE), critical high-demand items (such as batteries and breathing apparatus), equipment for reserve vehicles, and medical supplies for EMS units were insufficient for sustained operations. These challenges were overcome at the Pentagon with the aid of the more experienced Fairfax County Fire and Rescue Department logistics staff. A stronger standing capacity, however, is needed for a jurisdiction the size of Arlington County.
5. Hospital Coordination: Communications and coordination were deficient between EMS control at the incident site and area hospitals receiving injured victims. The coordination difficulties were not simple equipment failures. They represent flaws in the system present on September 11. Regional hospital disaster plans no longer require a Clearinghouse Hospital or other designated communications focal point for the dissemination of patient disposition and treatment information. Thus, hospitals first learned of en route victims when contacted by transporting EMS units, and EMS control reconstructed much of the disposition information by contacting hospitals after the fact. Although the number of victims of the Pentagon attack were fewer than many anticipated, they were not insignificant. An incident with more casualties would have seriously strained the system.
In summary, the response to the September 11 terrorist attack on the Pentagon was successful by any measure. Although the tragic loss of life from this horrific event could not be avoided, it was minimized. Had it not been for the heroic actions of the response force and the military and civilian occupants of the Pentagon, clearly the number of victims would have been much higher. Damage, although severe, was constrained in area and the fire was brought quickly under control. The fact that the response force did not suffer a single fatality or serious injury is testimony to the training, professionalism, and leadership of Arlington County and the response community. County Manager Carlee and Chief Plaugher further validated that leadership by requiring that a full and complete AAR be written so recommendations for improvement and lessons learned will be captured.
Although the response to the September 11, 2001, terrorist attack on the Pentagon is commendable, this AAR conveys 235 recommendations and lessons learned for improving response and rescue capabilities to better meet the challenges of this new threat environment. This important information should be
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shared with other jurisdictions around the country so the Nation benefits from Arlington County’s experience, both in preparing for mass casualty terrorist events and responding to them. Although this AAR is written for Arlington County, it should be read by the entire Nation.
Terrorism in any manifestation is an insidious phenomenon. It strikes without warning, often targeting innocent people. It is not intended to defeat an enemy by overwhelming military force, but to undermine and weaken its resolve. If the terrorists intended to weaken our resolve by attacking the Pentagon, they failed. In the words of Arlington County Manager Carlee, “The cowardly and evil effort to terrorize our community and our country served only to unite us more strongly than ever before.”
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ANNEX A
Arlington County After-Action Report
Fire Department Operations
INTRODUCTION
This annex describes the activities of the first responders from the Arlington County Fire Department (ACFD) and other supporting jurisdictions and agencies following the September 11, 2001, terrorist attack on the Pentagon.
The ACFD has three operational divisions, each managed by an assistant fire chief, and an Administrative Services Division. The Operations and Emergency Services Division is responsible for implementing the Department’s Life Safety, Emergency Medical, and Fire and Environmental Protection functions and for the training associated with those functions. The Technical Services Division is responsible for Apparatus and Equipment (A&E); the Fire Training Academy; Facilities Management; Hazardous Materials (HazMat) regulation and response; Emergency Preparedness; Wellness and Safety; Telecommunications; Logistics; and support for the ACFD’s portion of the Metropolitan Medical Response System (MMRS). The Fire Prevention and Community Services Division provides fire safety educational services to civic organizations, school children, businesses, hotels and motels, medical facilities in the county, and to county employees. It also reviews and evaluates building evacuation plans and coordinates various fire safety programs. The Administrative Services Division includes human resource management, ambulance billing and collection services, special projects, and administrative and clerical support services.
Figure A-1. ACFD organization.
The ACFD is a fully integrated fire and Emergency Medical Services (EMS) response organization. It employs 266 uniformed career firefighters and paramedics and 13 civilian staff members. Its mission is to eliminate threats to the lives, safety, and property of the Arlington community through education, prevention, and effective response to fire, medical, and environmental emergencies. There are 10 fire stations located throughout the county. (See Figure A-2.) During the past year, the ACFD responded to 23,619 emergency calls. Its 60 paramedics are assigned to 5 full-time and 2 peak-time EMS units, and 1 medic-capable engine. The ACFD operates with a minimum emergency medical staffing requirement for each of its 3 shifts of 15
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Introduction Fire Department Operations paramedics during the day and 11 at night. Paramedics are able to assess a patient’s condition; manage respiratory, cardiac, and trauma emergencies; administer intravenous fluids; use manual defibrillators; administer drugs; and perform other emergency procedures. Emergency medical technicians are called upon to respond to emergencies ranging from childbirth to automobile accidents to violence involving firearms and other weapons, and now terrorism. In addition, all ACFD firefighters are certified emergency medical technician-basic.
Figure A-2. Arlington County fire stations.
Arlington County Annex A After-Action Report Page A-2
Introduction Fire Department Operations
The ACFD is recognized as a highly professional organization and is one of only three fire departments in Virginia to hold a Class 2 Rating from the Insurance Services Organization, lowering insurance costs for homeowners and businesses. This is the highest rating received by Virginia fire departments.
This Fire Department Operations Annex includes information gathered from responders through debriefings, interviews, survey instruments, and by reviewing plans, documents, and transaction records. It is organized into eight sections. Each section describes activities related to a specific functional category. Those categories are: (1) Initial Response; (2) Command, Coordination, and the Incident Command System; (3) Communications; (4) Recall and Staffing; (5) Mutual-Aid and Outside Support; (6) Logistics; (7) Site Safety, Security, and Personnel Accountability; and (8) Planning, Training, and Preparedness.
The information in each of the eight sections is presented in three parts. First, a series of observations describes the nature of activities within the specific functional category, for example, Initial Response. The observations are followed by a set of findings reflecting the information gathered from responders in debriefings, interviews, and survey responses. Finally, each section includes a number of recommendations and lessons learned that are derived from the findings. In all, Annex A includes 111 recommendations and lessons learned.
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Fire Department Operations
SECTION 1: INITIAL RESPONSE
Observations
The only thing special about the morning of September 11, 2001, was the spectacular fall weather across the Washington Metropolitan Area. In Arlington County, the 67 firefighters and emergency medical technicians of the fire department’s “B” shift were staffing the county’s 10 neighborhood fire stations. By 8:30 a.m., training classes at the Arlington County Fire Training Academy were in full swing. Other ACFD personnel were engaged in meetings in the District of Columbia, preparing for the upcoming International Monetary Fund (IMF) conference. Several Arlington County chief officers were at a county- sponsored management class at the Fairlington Community Center. At 8:45 a.m., when American Airlines Flight #11 slammed into the north tower of New York City’s World Trade Center, it was abundantly clear this would be a day like no other. At 9:06 a.m., United Airlines Flight #175 crashed into the World Trade Center’s south tower, revealing the true nature of this unprecedented horror. A brutal, mind-numbing terrorist attack was under way against the United States.
In Arlington County, Captain Steve McCoy and the crew of Engine 101 were en route to a training session in Crystal City, traveling north on Interstate 395. Their conversation about the World Trade Center attack was interrupted by the sight of a commercial airliner in steep descent, banking sharply to its right before disappearing beyond the horizon. At 9:38 a.m., shortly after American Airlines Flight #77 disappeared from sight, a tremendous explosion preceded a massive plume of smoke and fire. Unable to pinpoint the precise location, Captain McCoy immediately radioed the Arlington County Emergency Communications Center (ECC), reporting an airplane crash in the vicinity of the 14th Street Bridge or in Crystal City. Aware of the World Trade Center attack, Captain McCoy also advised that the Federal Bureau of Investigation (FBI) should be notified, since this was a possible terrorist attack. Hearing the radio message, fire and rescue units from Arlington County and elsewhere began to respond, self-dispatching from stations or diverting from other destinations.
At 9:38 a.m. on September 11, only one fire crew, Foam 161 of the Fort Myer Fire Department, knew the exact location of the crash site. Captain Dennis Gilroy and his team were already on station at the Pentagon when Flight #77 slammed into it, just beyond the heliport. Foam 161 caught fire and suffered a flat tire from flying debris. Firefighters Mark Skipper and Alan Wallace were outside the vehicle at impact and received burns and lacerations. Recovering from the initial shock, they began helping victims climb out of the Pentagon’s first floor windows. Captain Gilroy called the Fort Myer Fire Department, reporting for the first time the actual location of the crash.
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Section 1: Initial Response Fire Department Operations
Fort Myer Foam 161.
Help was already on the way from several directions as units sped toward the source of the smoke plume, not toward a specific street address. ACFD Truck 105 reached the scene first, followed shortly by fire and medical units from several Arlington County stations.
Smoke billows from the Pentagon.
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Section 1: Initial Response Fire Department Operations
In the meantime, at the FBI Washington Field Office (WFO), Special Agent-in- Charge (SAC) Arthur Eberhart was putting in motion the steps necessary to support New York City. Of WFO’s four senior leaders, he was the only one present at headquarters that morning. Upon learning of the World Trade Center crashes, SAC Eberhart activated the WFO Command Center. Members of the WFO National Capital Response Squad (NCRS) were paged and instructed to report immediately to headquarters. Supervisory Special Agent (SSA) Jim Rice, the NCRS leader, was at the FBI WFO Command Center on the telephone with Mr. Larry Cirutti of the Military District of Washington (MDW) at the Pentagon when a monitored District of Columbia police radio transmission reported an explosion at the Pentagon. Mr. Cirutti told SSA Rice a helicopter must have “slid off the helipad” into the building. Special Agent Chris Combs, the NCRS Fire Service Liaison, was teaching a class at the District of Columbia Fire Academy when he received his page. While en route to the WFO Headquarters, he heard a news report of the Pentagon attack and proceeded directly to the Pentagon.
Meanwhile, at the Metropolitan Washington Airports Authority (MWAA) Fire Department at Ronald Reagan Washington National Airport, Captain Michael Defina was investigating an incident at Terminal B when he heard the impact and saw the smoke rising in the distance. He called Fire Communications and was advised of a report of a Boeing 757 crash off the end of Runway 1-19. That was quickly amended, identifying the Pentagon as the crash site. The MWAA contacted the Arlington ECC and was directed to respond to the Pentagon. They did so with substantial resources: a rescue engine, two foam units, two mass casualty units, a mini-pumper, and a command vehicle. Because MWAA has authority to respond automatically to an airplane crash within 5 miles of the airport, two heavy rescue units had already self-dispatched to the Pentagon.
ACFD’s Training Officer Captain Chuck Gibbs reached the incident site within the first 3 minutes, followed by Battalion Chief Bob Cornwell, who assumed initial Incident Command responsibilities. Those duties were quickly assumed by Assistant Fire Chief for Operations James Schwartz, who assigned Battalion Chief Cornwell, a 35-year veteran firefighter, to lead fire suppression efforts inside the building. Captain Gibbs commanded the River Division. Special Agent Combs arrived moments after Chief Schwartz. The partnership between Chief Schwartz and Special Agent Combs, who served as FBI agency representative to the Incident Commander, proved invaluable in the days ahead.
ACFD Captain Edward Blunt also arrived at the Pentagon within minutes of the crash and assumed EMS Control. He immediately contacted the ECC. Captain Blunt requested and immediately received a separate EMS operations channel. He also asked for 20 medic units, 2 buses, and a command vehicle (EMS Supervisor Vehicle 112) to support the EMS response. Captain Blunt designated the field adjacent to Washington Boulevard (Route 27) as the treatment area, and asked the Arlington County Police Department (ACPD) patrol units onscene to clear Washington Boulevard to create north and south access for emergency response traffic. Captain Alan Dorn arrived shortly after Captain Blunt, and was
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Section 1: Initial Response Fire Department Operations
assigned as Triage Officer. Together, Captains Blunt and Dorn began working with military medical personnel who volunteered to help set up triage areas.
Initially, medical units staged in the Pentagon South Parking Lot, adjacent to Route 110, until called forward to the EMS sector on Route 27. By 9:50 a.m., six ACFD EMS units had already arrived at the incident site (M-102, M-104, M-105, M-106, M-109, and M-110). M-101, Engine 103, and an ACFD Reserve Medic Unit quickly joined them. Two additional ACFD Reserve Medic Units (RM-111 and RM-112) arrived next and were directed to provide EMS support at the Pentagon’s Center Courtyard.
At 9:50 a.m., the ECC advised Captain Blunt that Virginia Hospital Center - Arlington, Inova Fairfax Hospital, and Washington Hospital Center were prepared to accept as many victims as needed.
The first ACFD personnel had arrived at the Pentagon within 2 minutes of the attack. ACFD and mutual-aid medical personnel began aiding victims immediately. Within 4 minutes of the attack, the ACFD had established its command presence. MWAA fire and medical units were on the scene and the first contingent of the FBI’s NCRS had arrived within 5 minutes of impact. Three major Washington Metropolitan Area hospitals were ready to receive injured victims 12 minutes after the attack. By 10:00 a.m. on September 11, most of the ACFD duty shift was engaged at the Pentagon.
Findings
The Pentagon is a highly visible and significant symbolic target, a structural fortress, populated by a large and highly disciplined workforce. Ongoing Pentagon renovation work lowered the number of potential victims. A portion of the impacted area was not yet fully repopulated following recently completed upgrades.
The massive size of the Pentagon and the complexity of its various rings, corridors, and floors compounded the challenge of the response force. First of all, it distorted the perception of the task at hand. It is true that fire damage was contained to a relatively small area, but it was a relatively small area in one of the largest business complexes in the world. This was office space built to accommodate a substantial workforce, with all the accompanying common space, meeting and conference rooms, and other support facilities.
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Section 1: Initial Response Fire Department Operations
View of external damage.
To those watching on television, or even from the Pentagon’s South Parking Lot, the gash created by the Boeing 757 airliner was large, but it affected a specific area of only two of the Pentagon’s five Wedges. Neither the depth of the incursion nor the massive devastation inside the building was readily apparent as flames burned behind blast-proof windows. Huge heaps of rubble and burning debris littered with the bodies and body parts of 188 victims covered an area the size of a modern shopping mall. The 189th victim subsequently died at Washington Hospital Center; all other injured victims transported to area hospitals survived. (See Appendix 4, Pentagon Penetration Damage Diagrams.) Flight #77 penetrated the outer wall of the Pentagon’s E Ring and the damage extended all the way through the inner wall of the C Ring, a distance of approximately 285 feet.
Penetration through the inner wall of the Pentagon’s C Ring.
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Several factors conspired favorably to support the firefighters on September 11. First of all, the weather was clear and dry and, for the most part, remained so throughout the next 10 days. Rain or heavy winds would have severely complicated the circumstances.
In addition, as a result of the congruence of scheduled meetings and training activities, the ACFD leadership team was gathered nearby and able to respond quickly. These fortuitous circumstances facilitated the immediate availability of Arlington County’s most experienced fire and medical services command personnel. Incident Command was established onsite within minutes of the attack and its authority was never challenged. The preparedness and ability of the ACFD leadership to take charge reflects exceptional training and a remarkable level of competence.
Internal damage to the Pentagon.
Additionally, just 1 minute before the Pentagon crash, in response to a 9-1-1 telephone call at 9:37 a.m., the ECC dispatched several units to an apartment fire at 1003 Wilson Boulevard in Rosslyn. Because it was located in a high-rise building, it was a substantial dispatch involving nine different fire and medical service units. Engine 103 reached the Rosslyn scene first and radioed that the apartment fire was out. Thus, by sheer coincidence, there were a significant number of units already on the road near the Pentagon at the time of the attack.
Furthermore, the fact that so many fire and rescue units from Arlington County and elsewhere self-dispatched immediately to the scene enabled fire suppression to commence without hesitation. This quick response was due in part to
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continuous national television and radio news coverage, which augmented the Arlington County ECC’s limited notification capabilities.
This rapid response also enabled the early provision of triage and treatment services for victims emerging from the Pentagon. Medical units from the ACFD and other jurisdictions treated and transported patients quickly, saving all viable victims, thanks to the support of military medical staff and the response of area hospitals.
However, some of these apparently favorable factors also had detrimental effects. Although self-dispatching quickened the arrival of a substantial number of fire, rescue, and medical units, many arrived haphazardly. The occupants of those vehicles were singularly intent on saving victims and attacking the fire. Police engaged in area traffic control were understandably reluctant to delay emergency vehicles descending on the scene with lights flashing and sirens blaring.
Deploying EMS units from other jurisdictions, particularly self-dispatched units, found it easy to bypass the staging area and proceed directly to the response site. Some victims flagged down EMS units before they reached the staging area. The crew from one Alexandria unit reported that it independently performed triage and treatment in the Pentagon South Parking Lot to assist five severely burned victims.
As a result, although the ACFD instituted Incident Command procedures very early on, they still faced the monumental challenge of gaining control of the resources already onsite and those arriving minute-by-minute.
Captain Jeff Liebold, working at the Incident Command Post (ICP), was tasked to determine what units were onsite and where they were working. Because radio communications were overloaded and ineffective, Captain Liebold sent two firefighters on foot to record the identification number and location of every piece of equipment on the Pentagon grounds. In the first few hours, foot messengers at times proved to be the most reliable means of communicating.
Additionally, the uncontrolled influx of fire and rescue personnel had important accountability implications. For example, Captain Gibbs established very effective entrance and exit controls at the Pentagon’s Corridor 5 entrance, near the impact point. However, firefighters and other personnel came and went from other Pentagon entrances sometimes with little or no control. Thus, had there been a second attack, as occurred at the World Trade Center, it would have been virtually impossible for the Incident Commander to determine quickly who might have been lost.
The unique design of the Pentagon hid from view activities at the Center Courtyard in the middle of the complex. Battalion Chief Jerome Smith was assigned responsibility for fire suppression from the Center Courtyard, with units from the District of Columbia and ACFD. His mission was to prevent the fire from breaching the B Ring. Upon reaching the Center Courtyard, Battalion Chief
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Smith found the area in turmoil. More than 400 building occupants crowded the Center Courtyard. Others leapt from the upper floors, as colleagues armed with fire extinguishers attempted to extinguish the flames consuming burning comrades.
EMS was also challenged by the unique design and the sheer size of the Pentagon; therefore, a complete and accurate sizeup of the incident site was not immediately performed. Those engaged in rescue efforts on the impacted west side of the Pentagon had little idea what was taking place at other locations, posing problems in establishing effective EMS Control. Although the central focus was the impact area on the west side of the Pentagon, not all the surviving victims evacuated in that direction. Some surviving victims found private ambulances or other means of transportation to area treatment facilities. Many reported to the DiLorenzo TRICARE Health Clinic (DTHC), located inside the Pentagon, close to the north entrance. The DTHC also set up EMS stations in the Center Courtyard and in the North Parking Lot.
Arlington County EMS unit onsite.
The ACFD EMS Control was not initially aware of the DTHC activities. The DTHC did not transmit patient disposition information to EMS Control. Thus, triage, treatment, and transport activities of the DTHC were not coordinated with EMS Control. Without a communications interface, important information on patient disposition was not captured. Had there been further catastrophe, it would have been next to impossible to ascertain a total victim count and identify Pentagon casualties, including those reporting to the DTHC treatment stations. As a result, records had to be reconstructed after the fact using information collected from hospitals and clinics to supplement information gathered onsite.
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Assistant Chief John White arrived at approximately 9:55 a.m., and was directed by Chief Schwartz to command the EMS Branch. Chief Schwartz advised him that Captains Dorn and Blunt were assessing and establishing mass triage sites at the traffic circle area of Washington Boulevard and westbound Columbia Pike. Captain Dorn organized responders and military volunteers, while Captain Blunt performed forward assessment. (See Figure A-3.)
Figure A-3. Initial triage and treatment sites.
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Section 1: Initial Response Fire Department Operations
Chief White instructed Captain Dorn to continue making preparations for casual- ties in the designated triage and treatment areas and to use the EMS units located along Route 27. ACFD triage and treatment sectors were established using ACFD assets, mutual-aid responders and military emergency medical technicians, nurses, and physicians. The military participants were receptive to direction and readily deferred to EMS officers. A military nurse equipped with a radio was able to communicate with the Defense Protective Service (DPS) and DTHC aid stations in the Pentagon.
Chief White then met with Captain Blunt along Route 27 adjacent to the Pentagon heliport for a forward assessment report. Chief White asked him for a count of the casualties in his area by triage designators: red (IMMEDIATE: Life Threatening Injury); yellow (DELAYED: Serious, Not Life Threatening); and green (MINOR: Ambulatory).
At approximately 10:15 a.m., Chief Schwartz ordered the immediate evacuation of the incident site. The FBI had warned him that a second hijacked airliner was flying on a course toward the Pentagon and was 20 minutes away. Responders were ordered to take shelter beneath one of the nearby highway overpasses. Chief White instructed Captain Blunt to ”load and go,” transporting as many patients as possible out of the area. The first wave of patients was en route to area hospitals within 10 minutes of the evacuation notice and all other personnel were relocated to the Columbia Pike underpass at the South Parking Lot. Medivac helicopters that had responded to the Pentagon incident scene were relocated to a safer place.
Evacuation by helicopter.
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Section 1: Initial Response Fire Department Operations
At the underpass, Chief White, in coordination with EMS officers and military medical volunteers, made plans to reestablish triage in that area. He designated Captain Dorn as Triage Officer, Captain Blunt as Forward Triage Officer, Chief Glen Butler from the MWAA as Treatment Officer, and Firefighter Paramedic David Hehr as Transportation and Disposition Officer. (See Figure A-4.)
Figure A-4. EMS Branch structure.
Dr. James Vafier, the Alexandria EMS Medical Director, accompanied an EMS unit to the incident site and was assigned a forward assessment role with a position on the sidewalk between Corridors 3 and 4. The plan was for military stretcher- bearers to carry victims extracted by firefighters to Dr. Vafier’s position for preliminary assessment. He would then assign them to the appropriate triage and treatment area.
When the all clear was sounded and site evacuation ended, EMS and military responders implemented Chief White’s operations plan. (See Figure A-5.)
Instead of the anticipated exodus of Pentagon patients, only 42 injured victims received on-site medical care and were transported to area hospitals. An estimated 100 additional victims were treated for minor injuries.
There are several reasons why the number of victims treated and transported by EMS units was less than anticipated: